ORIGINAL ARTICLE

Avoiding student infection during a Middle East respiratory syndrome (MERS) outbreak: a single medical school experience Seung Won Park1, Hye Won Jang1, Yon Ho Choe2, Kyung Soo Lee3, Yong Chan Ahn4, Myung Jin Chung3, Kyu-Sung Lee5, Kyunghoon Lee6 and Taehee Han7 1

2

3

4

5

Department of Medical Education, Departments of Pediatrics, Radiology, Radiation Oncology, Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Departments of 6Anatomy and 7Molecular Cell Biology, Sungkyunkwan University School of Medicine, Suwon, Korea

Purpose: In outbreaks of infectious disease, medical students are easily overlooked in the management of healthcare personnel protection although they serve in clinical clerkships in hospitals. In the early summer of 2015, Middle East respiratory syndrome (MERS) struck South Korea, and students of Sungkyunkwan University School of Medicine (SKKUSOM) were at risk of contracting the disease. The purpose of this report is to share SKKUSOM’s experience against the MERS outbreak and provide suggestions for medical schools to consider in the face of similar challenges. Methods: Through a process of reflection-on-action, we examined SKKUSOM’s efforts to avoid student infection during the MERS outbreak and derived a few practical guidelines that medical schools can adopt to ensure student safety in outbreaks of infectious disease. Results: The school leadership conducted ongoing risk assessment and developed contingency plans to balance student safety and continuity in medical education. They rearranged the clerkships to another hospital and offered distant lectures and tutorials. Five suggestions are extracted for medical schools to consider in infection outbreaks: instant cessation of clinical clerkships; rational decision making on a school closure; use of information technology; constant communication with hospitals; and open communication with faculty, staff, and students. Conclusion: Medical schools need to take the initiative and actively seek countermeasures against student infection. It is essential that medical schools keep constant communication with their index hospitals and the involved personnel. In order to assure student learning, medical schools may consider offering distant education with online technology. Key Words: Middle East respiratory syndrome, Emerging infectious disease, Medical students, Risk assessment

The rate of HCP-related infection with Middle East

Introduction

respiratory syndrome corona virus, Ebola virus, and severe acute respiratory syndrome (SARS) virus has been

In outbreaks of infectious disease, healthcare per-

reported to be around 1% to 27%, 2.5% to 12%, and 11%

sonnel (HCP) are at increased risk of contracting

to 57% of total cases, respectively [3]. It has been

emerging infections in the process of patient care [1,2].

suggested that early and rapid detection of suspected

Received: March 8, 2016 • Revised: April 15, 2016 • Accepted: April 21, 2016 Corresponding Author: Hye Won Jang (http://orcid.org/0000-0002-3053-7138) Department of Medical Education, Sungkyunkwan University School of Medicine, 81 Irwon-ro Gangnam-gu, Seoul 06351, Korea Tel: +82.2.2148.9906 Fax: +82.2.2148.9926 email: [email protected]

Korean J Med Educ 2016 Jun; 28(2): 209-217. http://dx.doi.org/10.3946/kjme.2016.30 eISSN: 2005-7288 Ⓒ The Korean Society of Medical Education. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Seung Won Park, et al : Avoiding student infection during MERS outbreak

infected patients with contagious diseases along with adequate infection control practice, education, and global

Subjects and methods

and national preparation guidelines could help prevent disease transmission to HCP [3].

SKKUSOM employs a 6-year curriculum divided into

Due to their participation in clinical clerkships,

three phases: a pre-medical phase (Years 1 to 2), a pre-

medical students should be considered to be at-risk HCP

clerkship clinical phase (Years 3 to 4), and a clerkship

during infectious disease outbreaks. When SARS struck

phase (Years 5 to 6). Students take classes from Year 1

Hong Kong in 2003, a number of medical students

to Year 3 at the main campus, which is located in a

contracted the disease as a result of exposure to SARS

different city 25 miles (40 kilometers) from the SMC.

patients [4]. Despite the fact that protecting medical

From Year 4, classes are held at the SMC as some

students from infection exposure is important, the

courses are designed to expose students to a clinical

literature on infection control practices for HCP appears

setting. When clinical clerkships begin in Year 5,

to focus mostly on healthcare professionals other than

students undergo core clerkship rotations throughout the

students [3,5].

whole year at the SMC, which is the main teaching

In the early summer of 2015, Middle East respiratory

hospital. During Year 6, students pursue clerkships in

syndrome (MERS) struck South Korea. There were 186

specific clinical disciplines of interest at the SMC as well

MERS-infected patients in the country, and 36 (19.35%)

as at two other affiliated hospitals: Kangbuk Samsung

died of the disease. Of the 186 MERS-infected patients

Hospital (KSH) located in the city of Seoul and Samsung

in Korea, approximately 50% were seen at the Samsung

Changwon Hospital located in the city of Changwon. On

Medical Center (SMC), the main teaching hospital

average, 40 students are enrolled in each academic year.

of Sungkyunkwan University School of Medicine

During the MERS outbreak, mainly students in Year 4,

(SKKUSOM), including five doctors and five nurses. The

5, and 6 were exposed to risk of contracting MERS.

SMC is one of the large tertiary hospitals in South Korea

Besides performing clinical clerkships, students attended

with about 2,000 beds, and on average, sees more than

lectures held in classrooms located at the main teaching

8,000 outpatients per day.

hospital (SMC). Thus, SKKUSOM students faced a

Given this circumstance, SKKUSOM administration was concerned with the possibility of students becoming

greater risk than those of other medical schools with a school building separate from their teaching hospital.

infected with MERS. In order to avoid a possible spread

In this study, we examined SKKUSOM’s efforts to

of the syndrome among the students, SKKUSOM took

avoid student infection during the MERS outbreak and

immediate action and made modifications to the regular

scrutinized the rationale behind the decisions made.

curriculum that restricted student presence at the SMC.

Through a process of reflection-on-action [6], we iden-

The purpose of the paper is to share the SKKUSOM’s

tified the necessary actions taken to ensure student

experience with the MERS outbreak and offer sugges-

safety and derived practical guidelines that medical

tions for medical schools to consider when faced with

schools can take to protect students in the face of

similar challenges.

outbreaks of infectious disease.

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Korean J Med Educ 2016 Jun; 28(2): 209-217.

Seung Won Park, et al : Avoiding student infection during MERS outbreak

2) Implementing safety measures to prevent po-

Results

tential spread of virus While the clerkships were halted, lecture classes

1. SKKUSOM’s actions against MERS

continued unless instructors were suspected to have MERS or have been exposed to patients with MERS. The

When the MERS outbreak occurred at the SMC, the

classrooms were initially considered to be free of MERS

SKKUSOM’s faculty council quickly organized an emer-

virus because they were housed in the cancer center of

gency committee to plan measures to protect students

the hospital separate from the index ward located in the

from infection exposure. The committee included the

main hospital building. The classrooms are also isolated

dean of the school; the vice deans of academic affairs,

from the clinical wards due to their locations on

education, and student affairs; the director of strategic

different floors. In order to prevent any potential

planning; a faculty member from the office of medical

transmission of MERS, the school had students follow a

education; and staff from the administrative office of the

set of precautions consistent with advice from the public

school. The committee held several meetings to deter-

health authorities. Precautions included (1) repeated

mine the best course of action for the circumstances.

handwashing and sanitizing, (2) taking daily temperature,

Three principles guided the decision-making processes:

and (3) using masks. The school provided sanitizers and

(1) ensuring student safety, (2) minimizing loss of

masks to students in every class. In addition, the school

student learning, and (3) reducing anxiety and concern

set up a monitoring team including a group of admini-

on the part of staff and students. Details of SKKUSOM’s

strative staff. The staff took student temperatures two

actions are discussed below.

times a day and kept track of their health statuses.

1) Discontinuing the clerkships

Through various channels, including text messages,

At the end of May 2015, the first Korean patient with

emails, and online and offline bulletin boards, students

MERS was reported at the SMC, and several nearby

were reminded of precautions and informed of a hotline

patients were subsequently identified as having MERS.

number to call in case they displayed some of the initial

One doctor also acquired the disease from the index

symptoms of MERS such as high fever and cough.

patient. SKKUSOM was immediately notified of these cases. Out of concern for the safety of our Year 5 and

3) Taking advantage of a break period to minimize learning loss

6 students performing clinical clerkship rotations at the

Despite efforts to screen out and quarantine suspected

hospital, the emergency committee was convened to

and infected patients in the hospital, the number of

develop a response. After closely communicating with

hospital-acquired infections dramatically and consistently

the SMC and consulting practitioners in the division of

increased. In response, the SMC was partially closed and

infectious disease, the committee acknowledged a high

stopped admitting outpatients. Although the school area

risk of infection exposure to MERS among students and,

was isolated from the clinical wards, several risk factors

as a result, decided to immediately discontinue the

of student infection were recognized. First, students

clerkship rotations.

shared some pathways with HCP at the SMC. An increasing number of faculty members were suspected to have contacted patients with MERS and were isolated at

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Seung Won Park, et al : Avoiding student infection during MERS outbreak

home. Because many classes were taught in small

providing the core clerkship program in another teach-

group-based learning formats such as problem-based

ing hospital of our medical school, KSH, which had no

learning, students had closer contact with instructors and

reported cases of MERS. KSH is a tertiary hospital that

peer students than they would in large lecture classes. In

has 33 clinical divisions and five speciality centers.

addition, given the fact that many medical students

Normally, students perform clinical clerkships at KSH in

spend a great amount of time and share living spaces

Year 6 for further training in specific disciplines of

(e.g., living in a dormitory) with their peers, infection of

interest.

one student could readily spread to multiple students.

The emergency committee directly contacted KSH

With continuous assessment of all these risk factors, the

executives and openly discussed the circumstances that

school leadership admitted an imperative need to

the school was confronting. After an honest and detailed

completely restrict student access to the hospital, which

discussion, KSH executives willingly agreed to host the

amounted to closure of the school.

core clerkship program in their hospital. Because this

While agreeing to the closure of the school, the faculty

change required additional effort and time to modify the

council expressed a concern that students would lose

existing clerkship program to be one suitable for the

legitimate learning opportunities owing to the can-

Year 5 students, the school assisted faculty members at

cellation of classes. In order to minimize such loss for

KSH with curriculum/program design. For example, the

the students, the emergency committee declared the

school provided sample rubrics for student evaluation

school closure period (4 weeks) to be the summer break

during the clerkships so that the faculty members can

and to continue the remaining courses after the break.

develop their own assessment tool. With full cooperation

This strategy was particularly practical because the

of KSH faculty, the school was able to minimize the loss

regular summer break at SKKUSOM was scheduled to

of student clinical-practice hours, and students success-

begin only 3 weeks ahead after the MERS outbreak

fully continued their core clerkships after returning

occurred. By moving up the summer break, although

from their break.

interruption in the regular curriculum was inevitable, the

5) Performing remote lectures and PBL tutorials

courses could still be carried out as originally planned,

With concern about possible spread of the disease at

and most class times were retained. 4) Arranging scheduled clerkships in another teaching hospital

the SMC after the break, the school also prepared remote lectures and classes so that students could continue their education without the risk of exposure to infection.

During the break, an increasing number of patients

Using a previously-installed remote lecturing system

with MERS were reported at the SMC. The school was

linking the hospital and the main campus, instructors

concerned with transmission of the disease in the

delivered lectures in the hospital classroom while

hospital even after students returned from the break. In

students took classes at the main campus. The lectures

addition, it was expected that the SMC would have

were video-recorded, and students simultaneously

difficulty offering ordinary clerkships because HCP were

watched the recorded lectures on a screen. With this

quarantined and a limited number of patients were

synchronous technology, the remote lecturing system

hospitalized due to the partial closure of the hospital.

allowed instructors and students to be as interactive as if

Given these circumstances, the committee considered

they were in the same classroom. In a similar way, we

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Korean J Med Educ 2016 Jun; 28(2): 209-217.

Seung Won Park, et al : Avoiding student infection during MERS outbreak

arranged PBL tutorials using a web-based video con-

formulated by the government or the public health

ferencing tool (i.e., Skype). Tutorial groups of students

authorities. Even if the course of infection is identified,

gathered at the main campus and tutors joined the groups

there is always a possibility of unwitting contact with

from the hospital via Skype. With such technology,

infected patients. Thus, in order to prevent possible

students and tutors were connected for the entire course

transmission of an evolving infection to students,

of the tutorial, and successfully executed the two

immediate cessation of clerkship rotations at teaching

scheduled tutorials.

hospitals is recommended at the onset of infection

2. Guidelines for avoiding student infection

outbreaks. There may be some opposition to the idea of man-

With these measures described above, SKKUSOM was

dating no patient contact for medical students in an

able to successfully protect students from MERS, as a

outbreak of epidemic. Their main argument is that

result, none of the 125 students developed an infection.

students should be treated as HCP, and medical students

Although having to reschedule the summer break, the

should confront the realities of professional life and gain

school fulfilled the required student training/education

experience with infection control measures including the

hours without major loss of student learning. Never-

use of personal protective equipment [10]. Although the

theless, there are a few things that could have been

students’ educational benefits of participating in the care

better. Based on our experience, we extracted a number

of a patient with an infectious disease should be ac-

of suggestions for medical schools to consider in case of

knowledged, we must also be mindful of the fact that

outbreaks of highly infectious agents such as MERS.

students are not yet qualified professionals who are

1) Instant cessation of clinical clerkships to re-

capable of coordinating their knowledge, skills, and

strict student access to the index hospital

clinical experience [11]. Thus, students cannot be ex-

It is critical that a school makes a timely decision on

pected to share the same risks and duties as professional

whether to stop clinical clerkships at the hospital

health care workers. It behooves medical schools and

housing infected patients. When SARS struck Hong Kong

hospitals to ensure student protection from a contagion.

and Toronto, suspension of clinical teaching was one of

2) Rational decision making on closure of the

the early interventions of the local medical schools to

school

protect their students [7,8]. Such decisions can be

In addition to cessation of clinical clerkships, school

challenging, especially when a disease is unprecedented,

administration might consider closing the school in order

because the impact of the disease might not be

to ensure student safety. The decision-making process

recognized. When the risk of infection is under complete

needs to be rational and flexible, examining various

control, clinical clerkships may offer a great learning

factors such as subsequent risk of student exposure to

opportunity for students [9]. However, when an in-

infection, schedules of the remaining classes, and the

fectious disease is relatively new, it is difficult to gauge

logistical possibilities of closure of a school [12]. In the

risk and identify the routes of transmission. We faced a

MERS outbreak, although suspending the clinical

similar situation in that the first patient identified with

clerkships, the school kept offering nonclinical teaching

MERS at the SMC was the very first case in South Korea,

sessions such as classroom-based lectures to minimize

and no infection control guidelines had yet been

the disruption of the regular curriculum. However, with

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Seung Won Park, et al : Avoiding student infection during MERS outbreak

the growing number of hospital-acquired infections, the

resistance from faculty and providing student and faculty

school leadership acknowledged that students were

training on use of the tools.

endangered even outside the patient-care environment.

4) Constant communication with teaching hospitals

Considering the need to balance student safety and

In a major infection outbreak like MERS, a hospital is

continuity in medical education, the school declared an

preoccupied with protecting their patients and HCP and

early summer break and closed the school temporarily.

could inadvertently overlook the safety of medical

3) Use of information technology

students who are performing clerkship rotations at the

One alternative to closure of the school is the use of

hospital. Medical schools are responsible for maintaining

information technology. When the outbreak of SARS in

constant contact with the teaching hospital so that the

Hong Kong prohibited all the schools from performing

schools are notified of an infection outbreak and are

teaching activities, the faculty of medicine at the

updated on the progress of the disease. In particular, it

University of Hong Kong provided narrated PowerPoint

would be well advised to establish a direct communi-

slides so that the students were able to listen to lectures

cation channel between practitioners at the teaching

at home [7]. With further advanced information and

hospital and the school personnel. With instant access to

communication technology, instructors can now deliver

critical information, medical schools are capable of

live, interactive lessons, not recorded lectures, to

making timely decisions to protect students against

students at remote sites. SKKUSOM used a remote

infectious disease.

lecturing system that linked classrooms in the hospital with those at the main campus. Both faculty and students were content with the remote lectures and tutorials given the state of emergency.

5) Open and candid communication with faculty, staff, students, and parents The school leadership needs to establish an open dialogue with all parties involved in order to prompt

Increasingly, elaborate and expensive hardware is no

their cooperation in executing decisions. For example, in

longer required to operate remote classes. There are a

our case, rescheduling lectures and clerkships rotations

number of web-based tools available for distance learn-

would have been impossible without the support of the

ing ranging from freeware such as Google Plus and

school administrative staff during the MERS outbreak.

Skype to more sophisticated virtual classroom tools like

These personnel played a critical role in monitoring

Adobe Connect, WebEx, and Wimba [13]. One of the

students. By involving administrative staff as core

advantages of web-based tools is that the individual

members of the emergency committee, the administrative

students can take a class from home as long as they are

team was able to acquire solid understanding of the

connected to the Internet. The use of such tools can

circumstances and provide full support in addressing the

substantially reduce the possibility of cross-infection

unusual situation. Similarly, direct and open communi-

while continuing education for medical students during

cation with the KSH faculty was the key to promoting

outbreaks of infectious disease. Medical schools may

their willingness to provide a substitute program for the

consider preparing to offer web-based courses in similar

regular clerkship. Medical schools generally have more

outbreaks that prohibit face-to-face meeting of indi-

than one affiliated hospital where students take clerk-

viduals. This preparation will include not only the

ships, and they are responsible for monitoring the

purchase of web-based tools, but also overcoming

clerkship schedules at each hospital and maintaining

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Korean J Med Educ 2016 Jun; 28(2): 209-217.

Seung Won Park, et al : Avoiding student infection during MERS outbreak

contact with hospital personnel in charge of student

students participating in patient care, the school leader-

education. With well-established channels of communi-

ship of SKKUSOM conducted ongoing risk assessment

cation with teaching hospitals, medical schools can

and reached key decisions to avoid student infection

acquire adequate cooperation of the hospitals with rapid

based on three principles: (1) ensuring student safety, (2)

curriculum changes in an emergency situation.

minimizing loss of student learning, and (3) reducing

In addition, proper communication with individual

anxiety and concern on the part of staff and students. In

faculty, students, and parents is necessary since they are

outbreaks of MERS and similar HCP-related infections,

the ones who are directly affected by changes in the

especially when infection control guidelines have not yet

curriculum. Decisions about the changes need to be

been provided by the government or public health

promptly delivered so that the key players are aware of

authorities, medical schools need to take the initiative in

the school’s actions against an infection outbreak and do

preparing countermeasures to protect students from

not receive erroneous information. In particular, the

infection exposure.

rationale of decisions needs to be detailed to aid full

First and foremost, it is critical that medical schools

understanding. In our case, the dean of SKKUSOM

maintain constant communication with teaching hos-

regularly emailed faculty, students, and parents to share

pitals and consult with health authorities and experts in

details of the school’s reactions to the evolving situation

infectious disease so that the schools can gauge the risk

during the MERS outbreak. This outreach helped min-

of student infection and make reasonable, timely

imize confusion, ease concern, and lessen feelings of

decisions to minimize risk. In order to ensure student

sacrifice.

safety, school leadership may immediately discontinue clerkships and even close the school as social distance measures has been found effective in limiting the spread

Discussion

of infections [16]. The decision to suspend all educational activities should be carefully made, taking into

In an outbreak of infectious disease, the risk of

account the need to balance appropriate precautions

transmitting a disease to HCP is unavoidable [14].

against the disruption to normal activities. The school

Medical students are also at risk of becoming infected

can opt to continue nonclinical teaching through the use

mainly due to clinical clerkship rotations at affiliated

of information technology. With web-based synchronous

hospitals, but they are often overlooked in plans to

technology, school can provide live lectures to students

prevent HCP infection [15]. Although students are not

at distance. Finally, the school should make a constant

yet professionals, they should be considered as HCP and

effort to communicate with those who are directly

protected from infection following the same standards as

involved including teaching hospitals, individual faculty,

those of other professional HCP. SKKUSOM confronted

staff, students, and their parents in order to acquire their

this issue when a MERS outbreak occurred in South

full cooperation in dealing with a difficult situation.

Korea. The students performed clerkships at the hospital where a number of patients with MERS had been reported, thus exposing them to risk of infection. Bearing in mind the benefits and risks involved with

ORCID: Seung Won Park: http://orcid.org/0000-0002-5012-8534; Hye Won Jang: http://orcid.org/0000-0002-3053-7138;

215

Seung Won Park, et al : Avoiding student infection during MERS outbreak

Yon Ho Choe: http://orcid.org/0000-0003-1525-7688;

Protecting health care workers from SARS and other

Kyung Soo Lee: http://orcid.org/0000-0002-3660-5728;

respiratory pathogens: organizational and individual

Yong Chan Ahn: http://orcid.org/0000-0002-1971-8472;

factors that affect adherence to infection control

Myung Jin Chung: http://orcid.org/0000-0002-6271-3343;

guidelines. Am J Infect Control 2005; 33: 88-96. 6. Schon DA. The reflective practitioner: how professionals

Kyu-Sung Lee: http://orcid.org/0000-0003-0891-2488;

think in action. New York, USA: Basic Books; 1983.

Kyunghoon Lee: http://orcid.org/0000-0003-0694-2499;

7. Patil NG, Chan Y, Yan H. SARS and its effect on medical

Taehee Han: http://orcid.org/0000-0002-7247-3283

Acknowledgements: None.

education in Hong Kong. Med Educ 2003; 37:

Funding: None.

1127-1128. 8. McGugan S. Medical school on bypass during the SARS

Conflicts of interest: None.

outbreak. Clin Invest Med 2003; 26: 106-107. 9. Huang Y, Xie W, Zeng J, Law F, Ba-Thein W. Limited knowledge and practice of Chinese medical students

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